Tips and Tricks for Problem Fractures [Volume I. The Upper Extremity] 9783030382735, 9783030382742

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Tips and Tricks for Problem Fractures, Volume I The Upper Extremity Daniel S. Horwitz Michael Suk Teresa K. Swenson Editors

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Tips and Tricks for Problem Fractures, Volume I

Daniel S. Horwitz  •  Michael Suk Teresa K. Swenson Editors

Tips and Tricks for Problem Fractures, Volume I The Upper Extremity

Editors

Daniel S. Horwitz Department of Orthopaedic Surgery Geisinger Health System Geisinger Musculoskeletal Institute Danville, PA USA

Michael Suk Department of Orthopedic Surgery Geisinger Medical Center Danville, PA USA

Teresa K. Swenson Department of Orthopedic Surgery Geisinger Medical Center Danville, PA USA

ISBN 978-3-030-38273-5    ISBN 978-3-030-38274-2 (eBook) https://doi.org/10.1007/978-3-030-38274-2 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

Orthopedic trauma continues to evolve at a rapid pace, based not only on changing technology but also on an expanded knowledge base and an understanding of the healing process. The vast increase in implant options has led to the necessity for continuous learning so that the technical aspects of any given procedure are understood. In conjunction with this, many instructional courses, both regionally and nationally, have shifted from an emphasis on historical literature and broad topic review to a focus on technical tips and tricks, with the goal of demonstrating how one actually performs a surgical procedure. This change has been widely praised and, as a result, has led to the development of this text. The goal of Tips and Tricks for Problem Fractures is to clearly communicate and visually demonstrate the detailed thought process and required surgical steps in order to avoid complications and achieve excellence, based on the experience of experts in each anatomic area. While not intended to be comprehensive in any sense, our hope is that experienced surgeons as well as residents in training can review these topics and come away with several “pearls of knowledge” that will aid them in their planning and execution of surgical treatments. Danville, PA, USA

Daniel S. Horwitz

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Contents

1 Clavicle Fracture: Open Reduction Internal Fixation������������������������������������������������������������������   1 Yelena Bogdan and Torre Ruth 2 Acromioclavicular and Sternoclavicular Joint Injuries������������������������������������������������������������������������  13 Mark Dunleavy and Damian M. Rispoli 3 Proximal Humerus Fractures������������������������������������������  25 Jaclyn M. Jankowski, Richard S. Yoon, and Frank A. Liporace 4 Humeral Shaft Fractures��������������������������������������������������  49 Mai P. Nguyen and Heather A. Vallier 5 Distal Humerus Fractures������������������������������������������������  67 Daniela Sanchez and Daniel S. Horwitz 6 Olecranon Fractures����������������������������������������������������������  83 Rodrigo Pesantez 7 Radial Head Fractures������������������������������������������������������ 103 Benjamin Richards Wagner and C. Liam Dwyer 8 Monteggia and Monteggia Variant Fractures ������������ 117 Michael Karl-Heinz Wich vii

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9 Fractures of the Distal Radius �����������������������������������  135 Daniela Sanchez, Daniel S. Horwitz, and Hemil Maniar 10

Scaphoid Fractures�������������������������������������������������������  147 Steven H. Goldberg

11 Lunate and Perilunate Dislocations: Tips and Tricks for Problem Fractures�������������������������������  163 Angela A. Wang and Brittany Garcia 12 Metacarpal Fractures: Tips and Tricks�����������������������  179 Anil Akoon and Joel Christian Klena 13 Phalanx Fractures: Tips and Tricks�����������������������������  199 Kirsten A. Sumner and Joel Christian Klena Index���������������������������������������������������������������������������������������  217

Abbreviations

A AC Acromioclavicular AP Anteroposterior ATLS Advanced trauma life support 3D Three-dimensional

C CC Coracoclavicular CRPP Closed reduction and percutaneous pinning CT Computed tomography

D DC DIC DIP DISSI DRC DSSI

Dynamic compression Distal intercarpal ligament Distal interphalangeal Dorsal intercalated segment instability Dorsal radiocarpal Double shoulder suspensory instability

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Abbreviations

E ER Emergency department

F FCR Flexor carpi radialis

G GPA Glenopolar angle

I IM Intramedullary

K K Kirschner

L LC-DCP Low contact dynamic compression plates LMA Laryngeal mask airway LUCL Lateral ulnar collateral ligament

M MCL Medial collateral ligament MIPO Minimally invasive plate osteosynthesis MRI Magnetic resonance imaging

Abbreviations

O ORIF Open reduction internal fixation

P PIP Proximal interphalangeal PRUJ Proximal radioulnar joint PT Physical therapy

R ROM Range of motion RSA Reverse shoulder arthroplasty

S SC Sternoclavicular/scaphocapitate SL Scapholunate

T THC Triquetrum-hamate-capitate

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Contributors

Anil Akoon, MD, MBA  Department of Orthopaedic Surgery, Geisinger Health System, Danville, PA, USA Yelena  Bogdan, MD Department of Orthopaedic Surgery, Geisinger – Holy Spirit, Camp Hill, PA, USA Mark  Dunleavy, MD  Penn State Health Milton S.  Hershey Medical Center, Hershey, PA, USA C. Liam Dwyer, MD  Department of Orthopaedics, Geisinger Medical Center, Danville, PA, USA Brittany  Garcia, MD Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA Steven  H.  Goldberg, MD Department of Orthopaedic Surgery, Geisinger Health System, Danville, PA, USA Daniel S. Horwitz, MD  Department of Orthopaedic Surgery, Geisinger Health System, Geisinger Musculoskeletal Institute, Danville, PA, USA Jaclyn  M.  Jankowski, DO Department of Orthopaedic Surgery, Jersey City Medical Center – RWJ Barnabas Health, Jersey City, NJ, USA Joel  Christian  Klena, MD Division of Hand Surgery, Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA

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Contributors

Frank  A.  Liporace, MD Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center – RWJ Barnabas Health, Jersey City, NJ, USA Hemil  Maniar, MD Musculoskeletal Institute, Geisinger Health System, Danville, PA, USA Mai  P.  Nguyen, MD Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA Rodrigo Pesantez, MD  Department of Orthopedic Surgery, Fundación Santa Fe de Bogotá, Bogotá, Cundinamarca, Colombia Damian M. Rispoli, MD  Musculoskeletal Institute, Geisinger Health System, Lemoyne, PA, USA Torre  Ruth, MD Department of Orthopaedic Surgery, Geisinger – Holy Spirit, Camp Hill, PA, USA Daniela  Sanchez, MD Musculoskeletal Institute, Geisinger Health System, Danville, PA, USA Kirsten A. Sumner, MD  Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA Heather A. Vallier, MD  Department of Orthopaedic Surgery, Case Western Reserve University, Metro Health System, Cleveland, OH, USA Benjamin  Richards  Wagner, MD Department of Orthopaedics, Geisinger Medical Center, Danville, PA, USA Angela A. Wang, MD  Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA Michael  Karl-Heinz  Wich, MD  Department of Trauma and Orthopedic Surgery, Unfallkrankenhaus Berlin, Berlin, Germany Richard S. Yoon, MD  Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center – RWJ Barnabas Health, Jersey City, NJ, USA

Chapter 1 Clavicle Fracture: Open Reduction Internal Fixation Yelena Bogdan and Torre Ruth

Introduction Clavicle fractures, particularly those of the midshaft, have traditionally been treated conservatively. However, several studies show improved functional outcomes with early fixation of these fractures though they are tempered by frequent need for plate removal. This section addresses both standard open and minimally invasive approaches to plating of midshaft clavicle fractures, implant choices, and plate placement.

Equipment Any standard system is amenable to clavicle plating, including various specialty plates and reconstruction plates that can be bent by the surgeon to fit the clavicle. A small Y. Bogdan (*) · T. Ruth Department of Orthopaedic Surgery, Geisinger – Holy Spirit, Camp Hill, PA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 D. S. Horwitz et al. (eds.), Tips and Tricks for Problem Fractures, Volume I, https://doi.org/10.1007/978-3-030-38274-2_1

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or mini-­fragment set is usually sufficient. For provisional fixation, 1.6  mm Kirschner wires and small reduction forceps can be used. For severely shortened fractures that are not immediately fixed, a mini-distractor can help bring the fracture out to length. If using a reconstruction plate, plate benders (either manual or tabletop) are helpful to contour to the S-shaped clavicle. Bone graft in the form of cancellous chips or other forms according to the surgeon’s preference can be available as needed though for most acute fractures it is rarely used.

Positioning Either the beach chair or a variant of the supine position can be used for clavicle fixation. In both cases, it is preferable to keep the entire arm prepped and available for range of motion throughout the surgery (Fig. 1.1). An arm holder for the beach chair may help bring the distal fragment superiorly, assisting with reduction. In the supine position, a vascular-­ type table with a central support rather than end support should be used as this will allow the C-arm to be brought in for the appropriate views (inlet and outlet views of the clavicle) at the head of the table (Fig. 1.2). For the pictured supine position, the table should be placed in slight reverse Trendelenburg for ease of access to the clavicle. A bump can be placed between the scapulae to help bring the clavicle forward [1]. A sloppy lateral position assisted with a beanbag or blankets is also helpful for bringing the operative site closer to the surgeon. The head of the patient should be turned away to the contralateral side in order to allow prepping and draping toward the ipsilateral ear. The medial one-third of the clavicle should be exposed by the drapes, including the sternal notch (Fig. 1.3). Prior to draping, preliminary X-rays should be performed to ensure adequate visualization. The contralateral clavicle should also be accessible for imaging if it is used as a template for plate bending.

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Figure 1.1  Supine positioning for clavicle plating. Entire operative arm must be exposed

Approach The two approaches most frequently used in the literature are the standard open approach and MIPO (minimally invasive plate osteosynthesis). Studies show similar union times in

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Figure 1.2  Use of a table that allows C-arm placement at the head for appropriate views

acute fractures between the two approaches [2]. In both cases, fluoroscopic views should be used to localize the fracture and plan the incision in order to avoid an excessively long scar in a visible area. The standard open approach involves an incision of variable length, usually 7–8  cm [3], centered over the fracture and planned approximately 1 cm below the clavicle as templated on fluoroscopy. The skin should be handled carefully, avoiding excessive retraction or cautery in this subcutaneous bone. After subcutaneous dissection, the platysma is released [1]. Beneath that, the supraclavicular nerves, which run perpendicular to the incision, are identified in the wound [1, 3]. Often there is a particularly prominent nerve in the lateral aspect of the incision. These nerves should be protected throughout the case, if possible, to avoid peri-incisional numbness. After this, the clavipectoral fascia along the clavicle should be incised [1], usually extending a rent through it made by the fracture. The fracture ends are identified and the bone exposed medially and laterally to make room for plate fixation. Small Hohmann retractors can be placed behind the clavicle to aid in exposure.

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Figure 1.3  The clavicle must be exposed medially up to the sternal notch

In the MIPO approach [4], a 2–3 cm lateral incision is first made along the anterior border of the clavicle as localized by X-ray. The dissection proceeds between the trapezius and the deltoid muscles, and the clavicle is exposed by detaching the deltoid from the bone’s superior surface. Following this, a tunnel is created from lateral to medial underneath the musculature with a periosteal elevator. Care is taken to keep the

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elevator along the bone, and avoid placement into the soft tissues near the vasculature and brachial plexus. A counter incision is then performed medially, and dissection proceeds in a lateral direction with the elevator in a similar fashion.

Reduction Techniques The standard open approach exposes the fracture fragments directly. They can be reduced using clamps of the surgeon’s choice, Kirschner wires (to hold butterfly fragments), or a mini-distractor [1] (Fig.  1.4). These clamps should not be placed deeply behind the bone to avoid injury to vessels and the brachial plexus [4]. The subclavian vein sits inferior to the clavicle, underneath the subclavius muscle, and the artery and brachial plexus are more posterior, deep to the anterior scalene muscle [1]. Regardless of plate position, these structures are approximately 8–12  mm away from the bone, and over-­ penetration of reduction tools, wires, or drills is ill-advised [5]. In the MIPO approach, the fracture is not exposed directly, and reduction is achieved primarily through fluoroscopic alignment [4]. K wires or 4.0 Schanz screws, placed out of the

Figure 1.4  Reduction of a clavicle fracture using clamps

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planned path of the plate, can be used as joysticks to align the fracture. One author recommends a 2 or 2.5  mm titanium elastic nail inserted medial to lateral as a temporary reduction tool [6]. The plate itself can also be used for reduction with attachment of screws laterally, followed by clamping of the plate to the medial fragment through the medial incision [4]. The screw placement sequence involves placing a locking drill bit into the most lateral plate hole, followed by a cortical screw in the third lateral hole to pull the plate to the bone. The locking drill bit should be pulled back slightly before screw tightening to avoid breakage. This is followed by a locking screw in the most lateral hole. The same process is repeated on the medial side [2, 4, 7].

Implant Choice Regardless of plate choice, at least three screws on each side of the fracture should be used [4] to ensure a stable construct. Pre-contoured specialty plates (Fig. 1.5) fit most clavicles but not all, and the surgeon must be prepared to bend the plate if necessary. Many of these plates have a cluster of lateral locking holes, which provide good fixation in osteoporotic bone. A 3.5 reconstruction or similar type plate, or multiple mini-fragment plates, will need to be contoured to fit the clavicle. In the direct approach, this is done in situ after the bone ends are reduced. In the MIPO approach, the curve of the unaffected clavicle on a caudal tilt X-ray [4] can be used as a template, or the plate can be bent prior to surgery using a sawbone clavicle. If a fluoroscopic templating approach is chosen, the plate bending proceeds lateral to medial [4]. For an anterior plate, the concave lateral bend is made first with a locking drill sleeve attached to the plate to avoid deforming the locking hole. This bend is aligned with the clavicle on fluoroscopy, and then the medial end is bent in a convex direction at the point where the clavicle begins to curve. For a superior plate, the contralateral clavicle is used as a template. The plate is flipped upside down, and the lateral and medial bends are made. This usually causes a deformation in the coronal plane and will require straightening [7].

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Figure 1.5  Pre-contoured plate used to treat a displaced fracture

Plate Placement Studies disagree over which placement construct, anterior or superior, has greater biomechanical stability. One study shows no differences in union rates or outcomes between the two in the MIPO approach [7]. The advantages of anteroinferior plating (Fig. 1.6) include aiming the screws in a posterior-­ superior direction, away from the vessels [1], less implant prominence, and the ability to place longer screws to improve purchase in the lateral clavicle. The superior plate (Fig. 1.7), on the other hand, has limited fixation in the lateral clavicle due to the thin bone in the superior-inferior direction. The double-plate construct (Fig.  1.8) is a relatively new method of plate fixation [3]. It is based on the idea that the natural motion of the clavicle is in multiple planes, and

Chapter 1.  Clavicle Fracture: Open Reduction...

Figure 1.6  Anterior clavicle plate

Figure 1.7  Superior clavicle plate

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Figure 1.8  Double plating method used to treat a displaced fracture. Scapular plates are also seen intraoperatively

therefore multiple planes of fixation are beneficial. It involves a standard open approach with a 2.4  mm locking compression plate placed anteriorly and a slightly longer 2.7

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Figure 1.9  Double plate construct with the plates bent to the shape of the clavicle

reconstruction plate placed superiorly (Fig.  1.9). The fracture pattern dictates which plate is fixed to the bone first. In at least one study, this construct was superior to the 3.5 reconstruction plate in multiplanar stiffness [3]. The smaller, low-profile plates may also decrease the need for implant removal.

Closure Deep closure should be limited to bringing the clavipectoral fascia to cover the plate. The supraclavicular nerves should remain protected and not tied tightly into the closure. Subcutaneous suture is then performed, followed by the skin. Suture choice is dependent on the surgeon and should strive to minimize scar formation.

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References 1. Collinge C, Devinney S, Herscovici D, et  al. Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle. J Orthop Trauma. 2006;20(10):680–6. 2. Sohn HS, Kim WJ, Shon MS. Comparison between open plating versus minimally invasive plate osteosynthesis for acute displaced clavicular shaft fractures. Injury. 2015;46(8):1577–84. 3. Prasarn ML, Meyers KN, Wilkin G, et  al. Dual mini-fragment plating for midshaft clavicle fractures: a clinical and biomechanical investigation. Arch Orthop Trauma Surg. 2015;135:1655–62. 4. Sohn HS, Kim BY, Shin SJ.  A surgical technique for minimally invasive plate osteosynthesis of clavicular midshaft fractures. J Orthop Trauma. 2013;27(4):e92–6. 5. Hussey MM, Chen Y, Fajardo RA, et  al. Analysis of neurovascular safety between superior and anterior plating techniques of clavicle fractures. J Orthop Trauma. 2013;27(11):627–32. 6. Lee HJ, Oh CW, Oh JK, et al. Percutaneous plating for comminuted midshaft fractures of the clavicle: a surgical technique to aid the reduction with nail assistance. Injury. 2013;44(4):465–70. 7. Sohn HS, Shon MS, Lee KH, et al. Clinical comparison of two different plating methods in minimally invasive plate osteosynthesis for clavicular midshaft fractures: a randomized controlled trial. Injury. 2015;46(11):2230–8.

Chapter 2 Acromioclavicular and Sternoclavicular Joint Injuries Mark Dunleavy and Damian M. Rispoli

Sternoclavicular Injuries Statistics and Introduction The most often cited incidence of sternoclavicular (SC) injuries is less than 3% of all injuries to the shoulder girdle from 1958 [1]. They are uncommon injuries often associated with high energy. Fractures of the medial aspect of the clavicle can also present challenges with respect to safe exposure and fixation. Bipolar injuries affecting both ends of the clavicle can present complicated and daunting challenges. Anterior dislocations present more commonly than posterior dislocations and can often be treated non-operatively. M. Dunleavy Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA D. M. Rispoli (*) Musculoskeletal Institute, Geisinger Health System, Lemoyne, PA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 D. S. Horwitz et al. (eds.), Tips and Tricks for Problem Fractures, Volume I, https://doi.org/10.1007/978-3-030-38274-2_2

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Anatomy Any motion of the shoulder results in movement at the SC joint. The clavicle rotates up to 40° along its longitudinal axis [2]. The clavicle is the first long bone to ossify (intrauterine week 5) and the last to fuse at its medial epiphysis (average 23–25 years of age with reports of delayed closure up to age 31) [3]. The medial clavicle provides the bony attachment sites of the clavicular head of the pectoralis major on its anterior surface, the sternocleidomastoid on its posterior surface and the sternohyoid on its inferior posterior surface. Inferiorly, there is a 2 cm roughened area for the attachment of the costoclavicular ligaments. The ligaments that comprise the soft tissue restraint of the SC joint are the capsular ligament which attaches predominantly to the medial physis (strongest) [4, 5] intraarticular disc (checkrein to medial displacement), costoclavicular ligaments (single most important constraint to SC motion) [6], and the interclavicular ligament (superior constraint) [7]. Posterior dislocation of the SC joint has the possibility of causing serious injury to the hilar structures. There are multiple reports in the literature of damage to the great vessels (trachea, esophagus, anterior neck vasculature, and brachial plexus). Clinical findings of hoarseness, dysphagia, or dyspnea should always prompt further clinical and radiographic evaluation. Unreduced posterior dislocations have been associated with thoracic outlet syndrome, vascular compromise, compression of the trachea and esophagus, and the risk of erosion into vital posterior structures. Despite these dire risks, few deaths have been reported in the literature because of posterior SC dislocations [8].

Imaging Plain radiographs of the SC joint are often time difficult to obtain and image quality can be less than satisfactory. The most accepted radiographic views are Serendipity view, a 40°

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cephalic tilt view [5], and Hobbs view (posterior to anterior with the neck parallel to the cassette) [9]. A computed tomography (CT) scan with or without three-dimensional (3D) reconstruction is the imaging study of choice for evaluation of the SC joint. On typical presentation in a polytrauma patient, determination of the presence or direction of dislocation is quite challenging, making the CT scan an indispensable tool.

Classification Simply defined with the direction of the dislocation.

Options Anterior Sternoclavicular Dislocation

The current literature supports the non-operative treatment of anterior sternoclavicular dislocations (69% good/excellent results) [10]. Surgical repair of the SC ligaments should be considered with unstable anterior dislocations in the presence of fracture requiring fixation. Suture material placed in the capsular ligaments may be fixated to the plate through drill holes in the clavicle or utilizing anchors in the medial clavicle.

Posterior Sternoclavicular Dislocation

Posterior SC dislocations should be treated with closed reduction with open reduction and fixation considered for unstable or irreducible dislocations. Closed reduction and open reduction yields good/excellent results in 96% [11].

Preferred Surgical Technique Patient Positioning

Patient placed supine on the operating table.

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A bump should be placed in the midline between the scapulae. The bump should allow for the shoulders to just comfortably lie on the surgical table surface. The affected shoulder should be just at or extending over the table’s edge to allow for maximal exposure. The upper extremity of the affected side should be draped free and the contralateral shoulder should be palpable to apply counter-traction or stabilize the patient on the surgical table while traction is applied to the affected side. It has been suggested that a folded sheet can be placed around the patient’s thorax in case counter-traction is needed to counteract the traction on the affected side. Care should be taken to drape and thus allow for appropriate cardiothoracic intervention in the unlikely event the assistance of a thoracic surgeon is required.

Closed Reduction Overriding Principle – distraction of the SC joint with anterior translation to reduce the joint. • Abduction: Laterally directed force with the shoulder abducted. Progressive extension of the shoulder. • Adduction: Traction applied to the adducted shoulder with concomitant downward pressure. A pointed towel clamp around the medial shaft of the clavicle or grasping the bone can be helpful to add a focused anterior translation to the medial clavicle.

Approach An anterior incision is used that parallels the superior border of the medial 3–4 inches of the clavicle. The incision extends downward over the sternum just medial to the involved SC joint.

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It is important to remove sufficient soft tissue to expose the joint but to still leave the anterior capsular ligament intact.

Procedure The medial clavicle should then be reduced back to its articulation with the manubrium. Suture repair of the anterior ligaments to grossly stabilize the SC joint with the goal of preventing recurrent posterior dislocation has been performed utilizing local or allograft tissue [11–14], plate or screw fixation [15, 16], or suture anchor stabilization [17]. Successful medial clavicular resection and ligament reconstruction have been noted to be successful [18–21]. Stabilization without bony resection is the preference of the senior author.

Post-operatively Patients should be placed in a figure-of eight dressing to hold the shoulders back for 4–6 weeks to allow for healing of the soft tissues.

Pearls and Pitfalls Use of K-wires, Steinmann pins, and smooth pins should be avoided given their documented propensity toward migration with untoward results [22]. The low numbers of reported outcomes from open reduction and fixation do not allow for differentiation between the various methods [10]. The most important factor affecting outcomes is time since injury; therefore, prompt diagnosis and treatment is optimal [10].

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Acromioclavicular Injuries Statistics and Introduction Acromioclavicular (AC) joint injuries are reported to have an incidence of 1.5–1.8 per 100,000 inhabitants per year, male:female ratio of 8.5:1, just over 50% occurring from age 20 to 39, and the two most common etiologies were sports (#1, cycling and contact sports) and motor vehicle collisions (#2) [23, 24]. Fractures of the lateral aspect of the clavicle can also present challenges for acromioclavicular joint repair with respect to reconstruction, repair, and fixation.

Anatomy The clavicle rotates up to 40° along its longitudinal axis [2]. However, due to synchronous scapuloclavicular motion there is only 5°–8° of rotation at the AC joint [25]. • Static stabilizers: AC joint capsule (posterosuperior ligaments – posterior translation) and the posterior and superiorAC ligaments (horizontal motion) [26].Coracoclavicular (CC) ligaments (conoid greater than trapezoid) as restraint to vertical translation [27]. • Dynamic stabilizers: Origin of the anterior deltoid and the insertion of the trapezius muscle [28].

Imaging Routine radiographs include true anterior-posterior and axillary lateral of the shoulder along with Zanca views (10°–15° degree cephalic tilt) [29]. Radiographs should be obtained in an upright position with the arm unsupported. A combined view including both acromioclavicular joints can be helpful for grading/classifying the injury and for surgical planning. A CT scan with or without 3D reconstruction can be of

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significant benefit in fractures with associated acromioclavicular joint disruption.

Classification [30] • Type I: AC ligaments and the joint remain stable • Type II: AC ligaments are ruptured (horizontal instability); CC ligament remains intact (vertically stable) • Type III: AC and CC ligaments are torn, resulting in complete AC dislocation • Type IV: AC and CC ligaments are torn and the distal end of the clavicle posteriorly dislocates • Type V: More severe version of a Type III injury (3 × normal CC distance). • Type VI: Inferior displacement of the clavicle

Options [31] Types I and II are universally treated non-operatively. Type III is controversial with most authors considering fixation in young active individuals. Types IV–VI are treated operatively. While measurement of the coracoclavicular distance may be beneficial in differentiating between types II and III, the senior author prefers to have the patients perform cross-arm abduction with the shoulder at 90° of elevation/abduction. If the lateral clavicle overrides the acromion, the injury is grossly unstable and should be operatively fixed.

Patient Positioning Beach chair configuration A small roll may be placed under the ipsilateral scapula to bring the shoulder forward (this allows good access to the superior aspect of the shoulder).

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Ensure proper placement of the fluoroscopy equipment to allow for intraoperative imaging. It is beneficial to prep the arm free to allow for manipulation of the arm and application of traction during surgery.

Open Approach Saber type skin incision 2–3  cm medial to the AC joint 6–10 cm. Full-thickness subcutaneous flaps are developed medially and laterally Incise the periosteum and reflect the deltotrapezius fascia in a medial to lateral direction at the junction of the anterior and middle third of the clavicle. Subperiosteal exposure of the lateral clavicle keeping the flaps continuous with the deltotrapezial fascia. Split the fibers of the deltoid anteriorly to expose the medial and lateral aspect of the coracoid base.

Fixation The overriding principle should be to place the torn ends of the CC ligaments together and hold them in this position for at least 6 consecutive weeks. Currently acceptable options include Hook plate (Balser) [32], screw fixation (Bosworth) [33], suture fixation (multiple authors), and ligament reconstruction (Weaver-Dunn, Jones, Mazocca) [34–36]. These techniques may be open, arthroscopic, or a combination of both.

Tips and Tricks Utilize a technique that you are comfortable and trained to perform. For most orthopaedic trauma surgeons, this involves an open procedure. Hook plates can be difficult to accurately place and require a second operation to remove

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the fixation but can give a satisfying and stable reduction. An open procedure using suture fixation can be a safe and straight forward method of fixation. Remember to keep bone bridges in the clavicle as wide as possible to avoid stress risers and intra- or post-operative fractures. Key your fixation of the clavicle to the coracoid off the reduced acromioclavicular joint. Use temporary K-wire cross fixation of the AC joint to hold reduction and ensure proper alignment of the clavicle and scapula. Expose the base of the coracoid by placing Homan retractors medially and laterally to ensure solid fixation and/or safe passage of grafts or suture.

References 1. Cave EF, editor. Fractures and other injuries. Year Book Publishers: Chicago; 1958. 2. Sewell MD, Al-Hadithy N, Le Leu A, Lambert SM.  Instability of the sternoclavicular joint: current concepts in classification, treatment and outcomes. Bone Joint J. 2013;95-B:721–31. 3. Webb PA, Suchey JM. Epiphyseal union of the anterior iliac crest and medial clavicle in a modern multiracial sample of American males and females. Am J Phys Anthropol. 1985;68(4):457–66. 4. Bearn JG.  Direct observations on the function of the capsule of the sternoclavicular joint in clavicular support. J Anat. 1967;101:159–70. 5. Rockwood CA Jr. Disorders of the sternoclavicular joint. In: Rockwood Jr CA, Matsen FA, editors. The shoulder. Philadelphia: WB Saunders; 1990. p. 477–525. 6. Kapanjii I. The physiology of joints, vol. 1. Baltimore: Williams & Wilkins; 1970. 7. Basamajian JV, Bazant FJ.  Factors preventing downward displacement of the adducted shoulder joint. J Bone Joint Surg. 1959;41A:1182. 8. Miller MD, Rispoli DM. Sternoclavicular disorders in Shoulder Surgery: An Illustrated Textbook. In: Wulker N, Mansat M, Fu FH, editors. Shoulder Surgery: An Illustrated Textbook. London: Martin Duntz; 2001. p. 451–461. 9. Hobbs DW. Sternoclavicular joint: a new axial radiographic view. Radiology. 1968;90:801–2.

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10. Glass ER, Thompson JD, Cole PA, Gause TM, Altman GT.  Treatment of sternoclavicular joint dislocations: a systematic review of 251 dislocations in 24 case series. J Trauma. 2011;70(5):1294–8. 11. Pearsall AW, Russel GV.  Ipsilateral clavicle fracture, sternoclavicular joint subluxation, and long thoracic nerve injury: an unusual constellation of injuries sustained during wrestling. AJ Sports Med. 2000;28(6):904–8. 12. Burri C, Neugebauer R.  Carbon fiber replacement of the ligaments of the shoulder girdle and the treatment of lateral instability of the ankle joint. Clin Orthop. 1985;196:112–7. 13. Bisson LJ, Dauphin N, Marzo JM.  A safe zone for resec tion of the medial end of the clavicle. J Shoulder Elb Surg. 2003;12(6):592–4. 14. Armstrong AL, Dias JJ.  Reconstruction for instability of the sternoclavicular joint using the tendon of the sternocleidomastoid muscle. J Bone Joint Surg Br. 2008;90:610–3. 15. Fery A, Leonard A.  Transsternal sternoclavicular projection: diagnostic value in sternoclavicular dislocations. J Radiol. 1981;62:167–70. 16. Brinkler MR, Bartz RL, Reardon PR, et al. A method for open reduction and internal fixation of the unstable posterior sternoclavicular joint dislocation. J Orthop Trauma. 1997;11:378–81. 17. Abiddin Z, Sinopidis C, Grocock CJ, et  al. Suture anchors for treatment of sternoclavicular joint instability. J Shoulder Elb Surg. 2006;15:315–8. 18. Porral MA.  Observation d’une double luxation de la clavicule droite. J Univ Hebd Med Chir Prat. 1831;2:78–82. 19. Dutta AK, Wirth MA, Rockwood CA Jr. Sternoclavicular joint injuries. Rockwood and Green’s fractures in adults. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 1243–75. 20. Marker LB, Klareskov B. Posterior sternoclavicular dislocation: an American football injury. Br J Sports Med. 1996;30(1):71–2. 21. Bicos J, Nicholson GP. Treatment and results of sternoclavicular injuries. Clin Sports Med. 2003;22:359–70. 22. Lyons FA, Rockwood CA. Migration of pins used in operations on the shoulder. J Bone Joint Surg. 1990;72:1262–7. 23. Nordqvist A, Petersson CJ.  Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elb Surg. 1995;4(2):107–12.

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24. Chillemi C, Franceschini V, Dei Giudici L, et  al. Epidemiology of isolated acromioclavicular joint dislocation. Emerg Med Int. 2013;2013:171609. https://doi.org/10.1155/2013/171609. Epub 2013 Jan 28 25. Flatow EL.  The biomechanics of the acromioclavicular, sternoclavicular, and scapulothoracic joints. Instr Course Lect. 1993;42:237–45. 26. Klimkiewicz JJ, Williams GR, Sher JS, Karduna A, Des Jardins J, Ianotti JP.  The acromioclavicular capsule as a restraint to posterior translation of the clavicle: a biomechanical analysis. J Shoulder Elb Surg. 1999;8:119–24. 27. Fukuda K, Caig EV, An KN, Cofield RH, Chao EY. Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg. 1986;8A:119–24. 28. Lizaur A, Marco L, Cebrian R. Acute dislocation of the acromioclavicular joint: traumatic anatomy and the importance of the deltoid and trapezius. J Bone Joint Surg. 1994;76:602–6. 29. Zanca P.  Shoulder pain: involvement of the acromioclavicular joint (analysis of 1,000 cases). Am J Roentgenol Radium Ther Nucl Med. 1971;112(3):493–506. 30. Rockwood CA, Green DP.  Fractures in adults, vol. 860. Philadelphia: Lippincott-Raven; 1984. 31. Simovitch R, Sanders B, Ozbaydar M, Lavery K, Warner JJP. Acromioclavicular joint injuries: diagnosis and management. J Am Acad Orthop Surg. 2009 Apr;17(4):207–19. 32. Balser D. Eine neue. Moethode zur operativve Behandlung der akromioklavikularen luxation. Chir Prax. 1976;24:275. 33. Bosworth BM. Acromioclavicular separation: a new method of repair. Surg Gynecol Obstet. 1941;73:866–71. 34. Weave JK, Dunn HK. Treartment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg. 1972;54A:1187–94. 35. Jones HP, Lemos MJ, Schepsis AA.  Salvage of failed acromioclavicular joint reconstruction using autogenous semitendinosus tendon from the knee: surgical technique and case report. Am J Sports Med. 2001;21:1277. 36. Mazzocca AD, Santangelo SA, Johnson ST, Dumonski ML, Arciero RA.  A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med. 2006;34:236–46.

Chapter 3 Proximal Humerus Fractures Jaclyn M. Jankowski, Richard S. Yoon, and Frank A. Liporace

Introduction Currently, proximal humerus fractures make up 7% of all fractures and 80% of all humerus fractures. In patients older than 65, proximal humerus fractures make up more than 10% of all fractures and are the third most common nonvertebral osteoporotic fracture following fractures of the distal radius and proximal femur [1]. There are a variety of treatment options for proximal humerus fractures, including non-­ operative management, percutaneous pinning, screw osteosynthesis, plating, intramedullary nailing, and arthroplasty (hemi, total, and reverse) [2]. According to Hasty et al., 85% of fractures between 2005 and 2012 were treated J. M. Jankowski Department of Orthopaedic Surgery, Jersey City Medical Center – RWJ Barnabas Health, Jersey City, NJ, USA R. S. Yoon · F. A. Liporace (*) Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center – RWJ Barnabas Health, Jersey City, NJ, USA © Springer Nature Switzerland AG 2020 D. S. Horwitz et al. (eds.), Tips and Tricks for Problem Fractures, Volume I, https://doi.org/10.1007/978-3-030-38274-2_3

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non-­operatively, but rates of operative management have significantly increased over that same period of time for all fracture types [3]. Our preferred method of operative management is open reduction internal fixation (ORIF) with a locked plate construct. The main advantages of locked plating are the ability to use the plate as an indirect reduction technique and the potential for short immobilization and early range of motion due to the high initial stability that can be achieved [4]. Clinically, ORIF shows trends towards greater post-operative range of motion when compared to non-operative management [5].The only significant difference in complications between operative and non-operative management is the rate of reoperation [6]. Prior studies have shown a 36% complication rate with ORIF but improved hardware and appropriate technique can mitigate and minimize these complications. For example, using a combination of convergent and divergent head screws increases pullout strength, and ensuring that screws are the appropriate length and are placed in the strong subchondral bone of the head can prevent cutout. Additionally, locked plates have decreased stiffness compared to non-locked plates, which allow them to withstand increased cyclic loading [2, 7]. If anatomic reduction is achieved and appropriate fixation techniques are utilized, ORIF can have good long-term results. Here, we review our preferred approach and provide case examples in which we use it.

 uthors’ Preferred Approach: General A Principles and Case Examples Our preferred approach to fixing proximal humerus fractures is the deltopectoral approach. While the deltoid split is also a viable option, as it arguably makes hardware placement easier, it does not allow for visualization of the more anterior bony and soft tissue landmarks that can often assist in obtaining desired reconstruction. Overall, through the deltopectoral

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interval, fixing proximal humerus fractures can be reliably performed via a stepwise approach, regardless of fracture pattern. This stepwise approach consists of the following: 1. Adequate exposure and bursectomy 2 . Tagging the greater and lesser tuberosities with non-­ absorbable suture 3. Provisional reduction and fixation of the plate to the proximal fragment 4. Non-locking fixation of the plate to the shaft, which restores valgus 5. Reinforcing fixation of tuberosities to the plate In general, following this stepwise method can allow for reliable, efficient reduction and fixation of proximal humerus fractures, regardless of fracture type. Our table preference is to perform the surgery on a beach chair, turned orthogonal with anesthesia, allowing imaging to come in from behind the patient. It is important to ensure that the endotracheal tube is facing the contralateral direction and one must use caution not to drape oneself out of the wound (you must be able to palpate the coracoid). Also, take note of any cardiac leads that may be in the way of imaging and ask anesthesia to move them accordingly. On the approach, the cephalic vein should be mobilized in the direction that it seems to favor, the subdeltoid space cleared bluntly, and the biceps tendon within the bicipital groove, which acts as a notable landmark for future plate placement. It is important to note that, especially in the elderly population, if the biceps tendon is damaged or chronically inflamed-appearing, an in situ pectoral tenodesis is performed. Clearing the hemarthrosis and bursal space is of utmost importance in order to identify the greater and lesser tuberosities for tagging with non-absorbable suture. Here the suture can be utilized as reduction aids in order to reconstruct the tuberosities with the head. With exposure achieved and suture placed and provisional reduction able to be achieved, the next step is plate fixation. Next, we review specific case examples exhibiting fixation sequence and strategies to obtain your desired outcome.

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Case 1: Avoiding Varus The patient is a 64-year-old female status post-fall from standing height. Patient sustained a right proximal humerus fracture (Figs. 3.1 and 3.2). Imaging analysis exhibited a large greater tuberosity fragment along with a separate lesser tuberosity fragment noted on computed tomography (CT) (Figs. 3.1 and 3.2). Here, heavy, non-absorbable sutures were used to tag and reapproximate the greater and lesser tuberosities, which were in close enough proximity to fix the proximal portion of the plate to head-tuberosities with Kirschner (K) wires (Fig. 3.3). Imaging confirmed appropriate plate height, and K wires were exchanged with locking screws with the plate still off of the shaft distally; fixing the proximal portion first allows for non-locking screw placement in the shaft, which will restore valgus (Fig. 3.4). Plate position is again checked and then the remaining screws filled in the head and shaft (Fig. 3.5). Once final fixation is complete, it is important to get multiple views (we prefer to

Figure 3.1  A 64-year-old female following a fall, here, an anteroposterior (AP) radiograph exhibiting a proximal humerus fracture with a large greater tuberosity fragment

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Figure 3.2  Axial CT imaging here, noted a separate lesser tuberosity fragment that was not readily obvious on plain radiographs

perform live fluoroscopy) to ensure that screw lengths are appropriate (Fig.  3.6). Reproducing this stepwise approach has offered efficient, reliable results for the majority of operative proximal humerus fractures.

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Figure 3.3  Following adequate exposure through the deltopectoral interval fixation of the tuberosities with non-absorbable sutures allows for provisional reduction and proximal plate fixation. Here, exaggerated positioning of the plate is desired

Case 2: Avoiding Impingement A 34-year-old right-hand-dominant male sustained a closed, right proximal humerus fracture status post-fall down the stairs. Radiographs exhibited a proximal humerus fracture

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Figure 3.4  The exaggerated plate position allows one to achieve further valgus once a non-locking shaft screw is placed

with a notable greater tuberosity fragment that was impacted and exhibited significant lateral prominence (Fig.  3.7). Advanced imaging via CT was performed and further delineated a tuberosity fragment that was “high-riding,” thus increasing the chance of impingement if treated non-­ operatively (Fig. 3.8).

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Figure 3.5  Prior to completely filling in with screws, ensure there is appropriate reduction and plate placement on the lateral view

This case is an important example of a fracture pattern that, if gone unrecognized, can do extremely poorly with non-­ operative treatment. Especially in a young person, reconstructing the greater tuberosity is essential to returning to overhead activities and avoiding impingement. Through the deltopectoral interval, our stepwise approach was applied; locked fixation into the head, followed by a non-

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Figure 3.6  Remember, once the construct is complete, it is important to use live fluoroscopic imaging to ensure appropriate screw lengths

locking screw in the shaft (Fig.  3.9), ensuring the plate is correctly positioned over a well-reduced fracture on the lateral (Fig. 3.10), completing the construct by filling in locked screws and an additional non-locking screw in the shaft (Fig. 3.11) and, finally, using live fluoroscopy to ensure that

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Figure 3.7  AP radiograph of a 34-year-old man exhibiting a right proximal humerus fracture with an impacted, lateral protruding greater tuberosity fragment

Figure 3.8  Coronal CT cut exhibiting a “high-riding,” impacted greater tuberosity, increasing risk for impingement, especially when combined with the lateral protrusion

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Figure 3.9  Following our systematic approach, suturing the tuberosities (following disimpaction of the greater) allows for reduction, proximal fixation followed by shaft screws to prevent varus

screw lengths are appropriate (Fig.  3.12). As another reminder, it is important to reinforce your tuberosity fixation by placing non-absorbable sutures through the plate to prevent further displacement, which can even be evident at final healing (Fig. 3.13).

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Figure 3.10  Follow the same steps, and check a lateral fluoroscopic image to ensure plate placement

Case 3: Supplemental Fixation As is the case with any fracture, goals of fixation include creating a stable, reliable construct that allows for confident, early range of motion. Here, a 52-year-old right-hand-­ ­ dominant male sustained a right proximal humerus fracture with a very large greater tuberosity fragment that seemed to extend posteriorly into the shaft (Fig.  3.14). Advanced imaging provided additional

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Figure 3.11  When satisfied, complete your fixation

information, exhibiting an impacted head (Fig. 3.15) along with a fracture in the coronal plane, which was the distal extension of the greater tuberosity piece (Fig. 3.16). Following our stepwise approach, length, alignment, and rotation were restored (Fig. 3.17). However, initially, the coronal fracture line was not addressed and was found to be gapping during intraoperative range of motion, despite additional suture fixation. Therefore, in order to prevent gapping, the fracture was clamped, held provisionally with a K wire, and then a 3.5  mm reconstruction plate was placed on the posteroinferior aspect of the greater tuberosity, providing ­

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Figure 3.12  Remember, the last step is to use live fluoroscopy to ensure appropriate screw lengths

supplemental fixation (Figs. 3.18 and 3.19). Coronal fracture line gapping no longer occurred and the patient healed uneventfully with range of motion nearly restored and symmetric to his uninjured side at the 1-year follow-up time point (Figs. 3.20 and 3.21).

Summary In summary, fixation of proximal humerus fractures, while challenging, can be made more facile by application of a systematic approach that follows the principles of obtaining

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Figure 3.13  Final follow-up radiograph, exhibiting healed fractures. Note the importance of suture fixation back-up for the tuberosity fragments that prevented further posterosuperior escape

appropriate exposure, suture fixation/mobilization of the tuberosity fragments, and sequential reduction via proximal fixation followed by a non-locking shaft screw to remove varus. Additional tricks, as described by the cases above, can further add to one’s arsenal in achieving stable, reliable fixation, allowing for early range of motion and an excellent functional outcome.

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Figure 3.14  AP radiograph exhibiting a large greater tuberosity fragment with seemingly distal extension of the fracture line posteriorly

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Figure 3.15  CT coronal cut showing an impacted head fragment into the shaft

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Figure 3.16  Axial CT cut exhibiting a coronal fracture line, which was the distal extension of the greater tuberosity fragment

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Figure 3.17  Again, exposure, suturing of the tuberosities, and proximal fixation followed by a non-locking shaft screw will help achieve a desired reduction

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Figure 3.18  Intraoperative shoulder range of motion noted gapping of the coronal fracture; thus an additional plate was placed to ­further strengthen the construct, allowing for early range of motion

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Figure 3.19  Dual-plate fixation with a proximal humerus locking plate and 3.5 mm reconstruction plate to buttress the greater tuberosity fragment, with appropriate positioning, and screw lengths on the lateral view

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Figure 3.20  AP radiograph exhibiting healed fracture. No penetration of the humeral head and appropriate plate placement

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Figure 3.21  Axillary radiograph exhibiting healed fracture with appropriate glenohumeral articulation and well-placed hardware

References 1. Streubel PN, Sanchez-Sotelo J, Steinmann SP. Proximal humerus fractures. In: Court-Brown C, Heckman JD, McQueen MM, Ricci WM, Tornetta P, editors. Rockwood and Green’s fractures in adults. Philadelphia: Wolters Kluwer Health; 2015. p. 13411425. 2. Schulte LM, Matteini LE, Neviaser RJ.  Proximal periarticular locking plates in proximal humerus fractures: functional outcomes. J Shoulder Elb Surg. 2011;20:1234–40. 3. Hasty EK, Jernigan EW, Soo A, Varkey DT, Kamath GV. Trends in surgical management and costs for operative treatment of proximal humerus fractures in the elderly. Healio Orthopedics. 2017;40(4):e641–7. 4. Sudkamp N, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. J Bone Joint Surg Am. 2009;91:1320–8.

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5. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part ­proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elb Surg. 2011;20:747–55. 6. Xie L, Ding F, Zhao Z, Chen Y, Xing D. Operative versus non-­ operative treatment in complex proximal humeral fractures: a meta-analysis of randomized controlled trials. Springerplus. 2015;4:728. 7. Brunner F, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009;23:163–72.

Chapter 4 Humeral Shaft Fractures Mai P. Nguyen and Heather A. Vallier

Humeral shaft fractures are defined as fractures from the surgical neck of the proximal humerus to the supracondylar ridge. Approximately 70,000 humeral shaft fractures occur annually and are estimated to be between 3% and 5% of all fractures [1]. These fractures have a bimodal age distribution with low-energy fractures such as falls from standing height in elderly patients and high-energy motor vehicle collisions, contact sports, falls from height, and gunshot injuries in younger patients. As with all trauma patients, a detailed history and physical examination is an important first step. Advanced Trauma Life Support protocol should be followed and careful attention paid to associated, potentially life-threatening injuries such as M. P. Nguyen Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA H. A. Vallier (*) Department of Orthopaedic Surgery, Case Western Reserve University, Metro Health System, Cleveland, OH, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 D. S. Horwitz et al. (eds.), Tips and Tricks for Problem Fractures, Volume I, https://doi.org/10.1007/978-3-030-38274-2_4

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scapulothoracic dissociation and pneumothorax. Neurological and vascular evaluation should be performed as injuries are frequent especially after high-energy trauma. The radial nerve is at risk due to its intimate relationship with the shaft in the radial groove. Prophylactic antibiotics should be administered urgently for open fractures, and tetanus immunization should be updated. Patients with ipsilateral humeral and forearm fractures should be closely observed for compartment syndrome. Standard orthogonal imaging should be obtained to view the entire humerus as well as the shoulder and elbow.

Case 1. Non-operative Treatment The patient is a 50-year-old, right-hand-dominant male who fell from a horse and sustained a right humeral shaft fracture with ipsilateral pneumothorax. He was evaluated in the emergency department and a coaptation splint was placed (Fig. 4.1). Care was taken to position the splint medially into the axilla and laterally over the superior aspect of the shoulder. A cuff and collar fosters positioning of the wrist superior to the elbow, reducing movement in the fracture and aiding in gravity-assisted reduction. He was advised to maintain an upright posture, even while sleeping, to maintain alignment and to reduce pain. One week later the patient was transitioned to a humeral fracture brace. Gentle longitudinal traction is placed on the upper arm while a capable assistant places the brace. Brace shape is customized, especially at the elbow to eliminate skin irritation, and the brace straps are securely fastened. The patient and family were advised to keep the brace on at all times and to tension the straps daily to maintain a snug fit. He was instructed on elbow, forearm, wrist, and hand active and passive motion as well as pendulum exercises for the shoulder. Active-assisted and passive shoulder range of motion exercises were instituted over the next few days. His fracture exhibited abundant callus at 6 weeks (Fig. 4.2), and he was instructed on removing his brace

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Figure 4.1  Fracture was initially maintained in a coaptation splint

for hygiene only, while continuing brace wear for another 3–4 weeks to protect the maturing bone. The humerus has a robust, vascularized soft tissue envelope, which facilitates its high union rate, 98% for closed fractures and 94% for open fractures in the Sarmiento series [2]. Most fractures can be treated non-operatively with a coaptation splint followed by fracture brace within 1–2 weeks after injury. Deformities including